Mindfulness and concentration practices
Within the Eastern-based meditation practices used in contemporary health care, there is a distinction between concentration practices and those intended to develop mindfulness or insight (Baer 2003). During concentrative practice, the meditator’s intention is to focus awareness on a particular object (e.g., a mantra, an image, the breath) and thereby limit attention and allow a deep concentration to develop (Zgierska et al. 2008). The intention in mindfulness meditation is for the practitioner to allow awareness to be present-focused and non-judgmental, and in doing so develop insight (vipassana) into the causes and conditions of suffering. While earlier studies focused on TM, a concentra- tive practice, recent research in addictions has shifted to a primary focus on mindfulness-based practices.
It has been proposed that mindfulness meditation might provide additional, specific benefit for individuals experiencing the craving and compulsive behavior characteristic of addiction (Groves and Farmer 1994). Indeed, results from an early trial of an intensive meditation course in an incarcerated population showed evidence of a significant relationship between participation in an intensive ten-day Buddhist “vipassana” meditation retreat and substance use, as well as psychosocial outcomes, when compared to participants in the “treatment as usual” condition (Bowen et al. 2006).
For many seeking treatment, however, a ten-day Buddhist meditation retreat may not be appropriate or feasible. As a result, several programs integrating cognitive behavioral approaches with mindfulness practice for alcohol and substance use disorder have been proposed (e.g., Bowen et al. 2009; Garland et al. 2014; Witkiewitz et al. 2005), providing practices to help clients step out of “automatic pilot” or destructive habit patterns into fuller awareness and flexibility. For example, mindfulness-based relapse prevention (Bowen et al. 2009; Witkiewitz et al. 2005) integrates cognitive behavioral relapse prevention treatment (Marlatt and Gordon 1985) with secularized mindfulness practices in an outpatient, eight-week program, designed to be accessible to a broad array of clients and settings. The intention is to offer the best of both Eastern and Western approaches in a format that can be implemented in medical and community treatment settings, and to avoid trappings or limitations of religion-based approaches.
Integration of mindfulness meditation into Western psychology appears to be taking two primary forms, with one fundamental factor that differentiates between the two approaches. In one school of “third wave” behavior therapies, mindfulness practices are integrated into a platform of CBT-based approaches as a supplementary practice, and are thus one of several components of the treatment. For example, dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) come from behavioral traditions but contain elements, components, or “modules” integrating mindfulness practice. In contrast, the other emerging group of therapies, recently termed mindfulness-based interventions or MBIs, have at their foundation, and thus part of every session, formal mindfulness meditation practices. These treatments ask their clients, beginning in the very first week, to adopt a daily formal meditation practice into their lives. Thus, third wave behavior therapies and MBIs differ mainly in the degree of focus on formal meditation practice; as one component (in DBT or ACT) versus the core focus of the treatment (in MBIs). The third wave behavior therapies and MBIs have fundamental similarities as well, including using mindfulness practices to help clients increase their focus on present-moment awareness, and learning to discern between what is actually happening in the present moment versus what stories or judgments the mind may be adding. Both have shown promise in the treatment of addictive behaviors.
Among the third wave of cognitive behavioral treatments, acceptance and commitment therapy (ACT) has emerged as a promising field of study (Hayes et al. 2006). Within this approach, the intention is not to change psychological processes, as in the case of more traditional cognitive behavioral therapies; rather, it is to change the individual’s relationship to such processes through the development of acceptance and mindfulness skills. According to an ACT model of psychopathology, addictive behaviors are the result of factors such as experiential avoidance, impulsivity, weak self-knowledge, and a lack of clarity of values (Hayes et al. 2006). Similarly, relief from these pathologies is believed to be achieved through increased psychological flexibility, which is developed through six core skills: (1) acceptance; (2) being present; (3) values; (4) committed action; (5) self as context; and (6) cognitive diffusion (Hayes et al. 2006; see also Bond et al. in Chapter 11 of this volume). The mindfulness skill of “being present” is defined as maintaining consistent, non-judgmental awareness of internal and external experiences. It is thus suggested that this awareness promotes a more direct experience of the world that enhances the individual’s ability to act in accordance with his or her value system (Hayes et al. 2006).
Several studies have shown promising results of ACT as a treatment for addictive behaviors. In a preliminary trial, ACT was shown to reduce illicit drug use among methadone-maintained opiate addicts, compared to intensive 12-Step Facilitation (see the next section on “The 12-Step tradition”) (Hayes et al. 2004). In another study assessing male and female inpatients at a residential treatment facility, participants receiving six hours of ACT had better treatment outcomes compared to those receiving treatment as usual (Luoma et al. 2012). Finally, in an outpatient setting for tobacco smoking cessation, participants receiving ACT reported better smoking outcomes at one year compared to those receiving nicotine replacement therapy (Gifford et al. 2004).
A related third wave approach is Spiritual Self-Schema therapy (3-S; Marcotte et al. 2003), a protocolled intervention that integrates a cognitive model of self within a Buddhist psychology framework, appropriate for people of all faiths. It was designed to help individuals struggling with addiction to develop a “selfschema” for compassion that supports abstinence from alcohol and other drugs, and HIV preventive behavior. To date, there have been no randomized controlled trials examining 3-S as a treatment for addiction. One small uncontrolled trial did find that 3-S was effective in changing several outcomes that are relevant to addiction, most notably impulsivity and motivation for change (Amaro et al. 2010). Another small trial found that participants in 3-S, in combination with methadone maintenance, showed greater reductions in impulsiv- ity and drug use than a non-randomized standard care group that included methadone maintenance without 3-S (Margolin et al. 2007).
Dialectical behavior therapy (DBT; Linehan 1993) is a skills-based therapy originally developed for the treatment of suicidal individuals and those with borderline personality disorder. DBT includes the addition of principles from Zen practices. The core mindfulness techniques encompass practicing observation of life experience, including one’s emotions and behaviors. The aim is for one’s emotional mind and reasonable mind to become balanced and joined into
“wise mind," which is capable of intuitive knowledge. The skills of observing, describing, and participating with one’s experiences are termed the “what" skills. The “how" skills involve taking a non-judgmental stance, focusing on one thing in the moment, and being effective. Through these techniques, clients not only develop better self-awareness but are able to participate wholly in activities with less judgment and worry. Ultimately, these mindfulness skills are important within all of the other DBT modules (emotion regulation, distress tolerance, and interpersonal effectiveness).
Several studies have been conducted assessing DBT for the treatment of addictions. A randomized clinical trial compared the efficacy of DBT to treatment as usual among women with borderline personality disorder drug dependence. Those in the DBT condition had significantly more days of abstinence from drugs and alcohol, corroborated by urinalysis results (Linehan et al. 1999). When DBT was compared to comprehensive validation therapy plus 12-Step (CVT + 12S) in treating opioid dependence in women with borderline personality disorder, both conditions reported reductions in opiate use. However, those in the CVT + 12S condition significantly increased opiate use during the final four months of treatment (Linehan et al. 2002). A recent review by Bankoff et al. (2012) indicated that DBT is also effective in reducing eating- disordered behaviors.